Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0124, written 27 Apr 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 27 Apr 2022 |
|---|---|
| Reference | 2022-0124 |
| Deceased | Natasha Adams |
| Coroner | James Bennett |
| Coroner area | Birmingham and Solihull |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths · Mental Health related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
1 2 3 4 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Solihull Mental Health Foundation Trust , Chief Executive, Birmingham and CORONER I am James Bennett, Area Coroner for Birmingham and Solihull CORONER'S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. INVESTIGATION and INQUEST On 23 August 2021 I commenced an investigation into the death of Natasha Mary ADAMS. The investigation concluded at the end of the inquest on 26 April 2022. CIRCUMSTANCES OF THE DEATH Natasha had a history of depressive symptoms and deliberate overdoses and was under the care of the mental health community team. She was last reviewed on 2 July 2021 following an escalation in symptoms when it was recognised she had emotional dysregulation. She was treated with medication and was to be reviewed again in October 2021. Late on 11 August she self- presented at the emergency department at Queen Elizabeth Hospital reporting recent fleeting suicidal thoughts of taking an overdose. She was assessed by the psychiatric liaison team to be in crisis but reported no immediate plan to take her own life. The liaison nurses wanted Natasha to attend the psychiatric decision unit for further assessment, but she had capacity to choose to go home, knowing that she would be referred to the home treatment team. She was not in fact referred until the evening of 12 August due to an administrative issue. Had she been referred, it is likely she would have been telephoned on the morning of 12 August when still alive. At approximately 8.45pm on 12 August she was found by a neighbour at home . She had left a note indicating her intention to end her own life. Following a post mortem the medical cause of death was determined to be: 1a Suspension by . The conclusion was death was due to suicide. CORONER'S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTER OF CONCERN is as follows. BSMHFT's Root Cause Analysis Report identified that in July 2021 Natasha's level of care level was downgraded from CPA to Care Support without clinicians following the trust's Care Management & CPA/Care Support Policy 2019. I heard evidence from Natasha's family this had a dramatic impact on Natasha's mental health. The RCA action plan identified the need to conduct an audit of other patients to check the trust's compliance with the Care Management & CPA/Care Support Policy 2019. The RCA Report was released in December 2021. The evidence was that 4 months later no action has been taken and other patients have not yet had their cases audited. The delay is the trust's Clinical Governance Committee needs to approve the audit process, which is unlikely to happen until the summer of 2022, and possibly not until as late as September 2022 because of staff holidays. In my view until such a delay is of serious concern and action should be taken to bring forward the audit. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 22 June 2022. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 5 6 7 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: , parents. 8 I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 27 April 2022 9 Signature: James Bennett Area Coroner for Birmingham and Solihull
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Date: 19 May 2022 James Bennett Area Coroner for Birmingham and Solihull HM Coroners Court 50 Newton Street Birmingham B4 6NE Legal Department B1 – Unit 1 50 Summer Hill Road Birmingham B1 3RB Sent via e-mail only Dear Mr Bennett, RE: PREVENTION OF FUTURE DEATHS REPORT Further to your Prevention of Future Deaths report in relation to the inquest for Natasha Adams I am writing to give you an update on progress. I understand that the report was given due to the lack of actions taken around the recommendation for the need to conduct an audit of other patients to check the trust's compliance with the Care Management & CPA/Care Support Policy 2019. Firstly I am very sorry that this action has not taken place. As a Trust we are taking our action plans very seriously and are working to improve patient care for the future, where lessons are identified within our Serious Incident reviews. With respect of this particular recommendation; the delays in completing our audit of compliance against our Care Programme Approach (CPA), the national care management approach in mental health, was due to capacity constraints caused by the recent Covid-19 Omicron surge and its effect on increasing staff sickness. I can now assure you that we are fully committed to accelerate the completion and reporting of this audit through our clinical governance route. The audit was undertaken by the Head of Nursing and Allied Health Professionals on 12 May 2022. I can confirm to you that the results from the audit showed that 80% of the patients reviewed had received a formal CPA review prior to any change. Whilst 20% of the records did not have formal CPA review completed there was evidence by the Care coordinator of the approach outlined in the policy. The policy states: 3.4.8 Where it is not possible to convene a single meeting of all involved the review may comprise of a series of conversations and/or reports coordinated by the Care Coordinator . In these cases, the Care Coordinator should complete the process by recording all of the decisions made in the CPA review form on RIO. Only 1 record did not contain evidence of a discussion taking place. The results will be reported through the next clinical governance group, which will take place in 24 May 2022. Customer Relations │ Mon – Fri, 8am – 6pm Tel: 0800 953 0045 │ Text: 07985 883 509 Email: bsmhft.customerrelations@nhs.net Website: www.bsmhft.nhs.uk F a x : 0 1 2 1 1 3 0 1 3 0 3 We are committed to making the changes within the action plan as well as continually identifying where further improvements can be made to ensure safe and high-quality care for all of our service users now and in the future. Yours sincerely Chief Executive Customer Relations │ Mon – Fri, 8am – 6pm Tel: 0800 953 0045 │ Text: 07985 883 509 Email: bsmhft.customerrelations@nhs.net Website: www.bsmhft.nhs.uk
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